Many practices assume that services without regular CPT codes are automatically non-covered and payable by the patient. At the same time, codes with allowed amounts listed in the Medicare Physician Fee Schedule (MPFS) are presumed to be covered and paid by Medicare.
However, although Category III codes (“T-codes”) and miscellaneous CPT codes (codes ending in “99”) are not included in the MPFS and do not usually have reimbursement values assigned, that does not mean they are always non-covered.
Background and examples
For several years, Medicare Administrative Contractors (MACs) frequently had local coverage determination (LCD) policies that categorically identified services described as non-covered unless there was a specific coverage policy. That changed in 2019 when the 21st Century Cures Act
of 2016 went into effect. Since then, MACs have been prohibited from issuing blanket non-coverage LCDs. Instead, they are expected to determine coverage on a case-by-
case basis. This affects a variety of services provided in ophthalmic or optometric offices, including, but not limited to:
• 0207T - Evacuation of meibomian glands, automated, using heat and intermittent pressure,
unilateral
• 0330T - Tear film imaging
• 0333T - Visual evoked potential, screening of acuity, automated, with report
• 0402T - Collagen cross-linking of cornea, including removal of the corneal epithelium when performed, and intraoperative pachymetry, when performed
• 0464T - Visual evoked potential, testing for glaucoma, with interpretation and report
• 0563T - Evacuation of meibomian glands, using heat delivered through wearable, open-eye eyelid treatment devices and manual gland expression, bilateral
How to approach
Before considering these services non-covered and asking patients to pay, practices have some work to do. Some MACs have coverage policies for specific Category III and miscellaneous codes.
Where there is no policy, the only way to know if a service is covered by Medicare is to submit a claim. Several factors impact coverage and payment and should be considered:
• Absent an LCD, coverage is determined on a claim-by-claim basis
• Alternately, coverage follows LCD and associated local coverage article (LCA), which lists covered/
noncovered ICD-10 codes
• A listed payment rate ($) does not guarantee
coverage
• An unlisted payment rate (n/a) does not mean
noncovered
Non-Medicare plans, including Medicare Advantage plans, which may have their own instructions, do not automatically apply Medicare’s policy to all payers. Take advantage of the payer’s preauthorization process, when available. In addition to clarifying coverage, you can get information on payment rates so you are not blind-sided by a payment rate that is too low.
For these services, the practice will need to establish a protocol, which involves two steps:
1. Determine coverage status:
• Find out if a statute, regulation, NCD, LCD, or LCA applies
• Think about whether the item or service is “experimental” or “investigational”
• Contact payer for prior authorization or predetermination
• Assess limitations of coverage (ICD-10 codes)
• Consider that ambiguous coverage status usually requires a claim
• Don’t use fee schedule as a proxy for coverage
2. Determine reasonable and defensible fee:
• Use comparable procedures as a guide
• Consider time and resources
• Review current fees
While there may be temptation to simply assume coverage is not likely and decline to submit a claim, submitting a claim is not optional in most cases. Participating or non-participating physicians are required to file a claim unless you know for certain a service is not covered. For example, statutorily excluded services, like refraction, are exempt.
Clarity on ABNs
There tends to be some confusion over the use of an advance beneficiary notice (ABN) or waiver in these cases. Payment for non-covered services is the beneficiary’s responsibility, but Medicare Law (§1879) contains a provision that waives that liability if the beneficiary is not likely to know and did not have a reason to know that the services would not be covered. If the beneficiary does not receive proper notice when required, they are relieved from liability. The provider is then responsible rather than the patient. An ABN should not be used to avoid submitting a claim and transfer the financial responsibility to the patient.
Other problems with ABNs include when:
• It is unreadable, illegible, incomprehensible
• The beneficiary is incapable of understanding it
• It is given during an emergency
• The beneficiary is coerced, misled, or under duress
• It is routinely given to all beneficiaries
• Notice is given more than 1 year prior to furnishing
• The beneficiary is given a mere statement of possibility that Medicare may not pay for an item or service
• Notice is given by telephone
Without notice of noncoverage prior to the service being provided, the Medicare beneficiary is not financially responsible. A refund may be due if the beneficiary made a payment without following this process.
Medicare Advantage Organizations (MAOs) are not permitted to use the official ABN form. In May 2014, CMS reminded MAOs that they are obliged to make pre-service determinations of benefits for each plan. Either patients or providers can request it — and they should!
Non-Medicare beneficiaries have limitations on coverage as well, usually based on their contract. For these patients, there may be more latitude in notification. Consider getting a predetermination (prior authorization) when you can. While the ABN cannot be used for these patients, a Notice of Exclusion from Healthplan Benefits form is useful to clearly inform patients about coverage and financial responsibility. Many practices make up their own forms for this purpose, which are loosely modeled on the Medicare ABN form. Customize it to fit your practice’s needs.
Conclusion
The variety of payer plans coupled with the lack of policies regarding noncovered services can cause confusion with staff and patients. To avoid this confusion, set a protocol in advance, train your staff, and provide them with information to share with patients. Then, document the patient’s choice on a suitable waiver. OP
Ms. Johnson is a Certified Professional Medical Auditor and a Certified Professional Coder by the American Academy of Professional Coders. She has also obtained the Certified Ophthalmic Executive (COE) designation. Ms. Johnson conducts business from the Corcoran Consulting Group’s North Carolina office.
